1STAR+PLUS Capitation Structure Sample Clauses

1STAR+PLUS Capitation Structure. (a) STAR+PLUS Rate Cells. STAR+PLUS Capitation Rates are defined on a per Member per month basis by Rate Cells. STAR+PLUS Rate Cells are based on client category as follows: (1) Medicaid Only Standard Rate (2) Medicaid Only 1915 (c) Nursing Facility Waiver Rate (3) Dual Eligible Standard Rate (4) Dual Eligible 1915(c) Nursing Facility Waiver Rate (5) Nursing Facility – Medicaid only (6) Nursing Facility - Dual Eligible These Rate Cells are subject to change after Rate Period 2. (b) STAR+PLUS Capitation Rates For All Service Areas, HHSC will establish base Capitation Rates by Service Area based on fee-for­service experience in the counties included in the Service Area. For the base Capitation Rate in the ▇▇▇▇▇▇ Service Area, the encounter data from existing STAR+PLUS plans in ▇▇▇▇▇▇ County will be blended with the fee-for-service experience from the balance of counties in the ▇▇▇▇▇▇ Service Area. HHSC may adjust the base Capitation Rate by the HMO’s Case Mix Index to yield the final Capitation Rates. HHSC reserves the right to trend forward these rates until sufficient Encounter Data is available to base Capitation Rates on Encounter Data. (c) Delay in Increased Capitation Level for Certain Members Receiving Waiver Services Once a current HMO Member has been certified to receive STAR+PLUS Waiver (SPW) services, there is a two-month delay before the HMO will begin receiving the higher capitation payment. Non-Waiver Members who qualify for STAR+PLUS based on eligibility for SPW services and Waiver recipients who transfer from another region will not be subject to this two-month delay in the increased capitation payment. All SPW recipients will be registered into Service Authorization System Online (SASO). The Premium Payment System (PPS) will process data from the SASO system in establishing a Member’s correct capitation payment.